Monday, December 23, 2002

I'm going over the fence --

From 23 Dec 02 (today) until 30 Dec 02, I will be away from my office, my laptop, my Internet connection, and my news fix while I travel to New York and New Jersey. Feel free to e-mail me with any comments or holiday wishes, but I probably won't reply or add any new commentary until I return. Happy Holidays!

Sunday, December 22, 2002

Smallpox and Dark Winter

The RAND Corporation recently issued a study in the New England Journal of Medicine arguing against mass smallpox vaccinations. Unlike most RAND research, which provides illuminating and valuable policy advice, this report gets the story and recommendations wrong. In an age of terrorism and 4th Generation Warfare, mass vaccination against this potent weapon is an absolute imperative. UCLA Professor Mark Kleiman blogged something about this earlier, but I wanted to add some thoughts based on my experience in the field.

The words "Dark Winter" will bring a shiver to anyone who has read about the exercise and the results & recommendations it produced. "The Dark Winter exercise portrayed a fictional scenario depicting a covert smallpox attack on US citizens. The scenario is set in three successive National Security Council (NSC) meetings (Segments 1,2 and 3) which take place over a period of 14 days. Former senior government officials played the roles of NSC members responding to the evolving epidemic; representatives from the media were among the observers of these mock NSC meetings and played journalists during the scenario's press conferences (see Participant List). The exercise itself was held at Andrews Air Force Base, Washington, D.C. on June 22-23, 2001." (see the Dark Winter website at Johns Hopkins University)

This exercise produced some staggering results; an unclassified summary is available in the February online Journal of Clinical Infectious Diseases. Among the results were:

- Leaders are unfamiliar with the character of bioterrorist attacks, available policy options, and their consequences.
- After a bioterrorist attack, leaders' decisions would depend on data and expertise from the medical and public health sectors.
- The lack of sufficient vaccine or drugs to prevent the spread of disease severely limited management options.
- The US health care system lacks the surge capacity to deal with mass casualties.
- To end a disease outbreak after a bioterrorist attack, decision makers will require ongoing expert advice from senior public health and medical leaders.
- Federal and state priorities may be unclear, differ, or conflict; authorities may be uncertain; and constitutional issues may arise.
- The individual actions of US citizens will be critical to ending the spread of contagious disease; leaders must gain the trust and sustained cooperation of the American people.

ANSER, another organization involved with this exercise, had this "lesson learned" from the exercise: There is no surge capability in the US health care and public health systems, or the pharmaceutical and vaccine industries. This institutionally limited surge capacity could result in hospitals being overwhelmed and becoming inoperable; could impede public health agencies' analysis of the scope, source and progress of the epidemic, the ability to educate and reassure the public, and the capacity to limit causalities and the spread of disease.

Bottom Line: There is significant risk in the smallpox vaccination program. But there is a much larger risk in choosing not to go forward with a mass vaccination program, or to only vaccinate 1st responders and health-care workers. Anti-terrorism operations all boil down to a systematic allocation of risk. The results of Dark Winter -- the most advanced simulation of a smallpox attack on the U.S. -- argue strongly for mass vaccination as a way of managing this risk.
Breaking news - French reporter killed during U.S. exercises in Kuwait

I just read the terrible news that a French reporter covering the U.S. Army's exercises in Kuwait was killed by an M1 tank. The Associated Press reports:

During exercises Saturday, French journalist Patrick Bourrat was struck while crossing the path of an incoming tank and thrown 15 feet into the air. He died at a hospital early Sunday of massive internal injuries.

Military exercises, like war, are inherently dangerous. Even the most skilled units and competent leaders make mistakes in exercises; soldiers often get hurt or killed in such exercises. But realistic exercises in peacetime are important. The harder our troops train in peace; the more they sweat and push the envelope -- the better they will do in combat. We will lose less lives in combat if we take risks in training. The average Army or Marine officer takes these risks very seriously, because they value the life of every one under their command. They manage these risks as much as possible. But the risks are still there.

Reporters ought to cover such training exercises, and they ought to report on them for the global audience. However, reporting on military exercises (like reporting on war) carries certain risks. This accident is tragic. But it must be seen in its proper context, and understood as a necessary and unfortunate consequence of military training.